Reserapport - utresande lärare
Lärosäte: University of Malawi
Utbildningsprogram: Barnmorska
Utbytesprogram: Linnaeus-Palme
Termin: Hösttermin 16/17
Antal dagar: 23
Namn: Johanna Sarlio-Nieminen


I was met at the airport by the driver of Kamuzu College of Nursing. As is custom, a visitor to College (and to Malawi) one is to have an invitation from the receiving institution and I was carrying one by Dean of Faculty of Midwifery, Neonatal and Reproductive Health Studies.

I had personally booked my accomodation in both Lilongwe and Blantyre using -online services. In Lilongwe I stayed in Joe's Lodge and in Blantyre similarly in two lodges (Homes Up and Kabula Lodge). In rural site I stayed in a small house that researchers and Peace Corps volunteers in the area used for shorter stays in Mangochi town. Standard of accomodation was modest but homely in all four places.

General cost of living in one of the poorer countries of sub-Saharan Africa is low for Northerners, but imported goods and most services for tourists/visitors are beyond means for local people. 

Kamuzu College provided transport within town.  


Språk och kultur

English is used in all education after primary level in whole of Malawi. Teaching and communicating in English was thus not a problem. 
I had learned some local Chichewa during my earlier stays in Malawi, which makes communication even more joyful, but is not a requisite for operating in the country and as an exchange-teacher.

In Malawi visitors are welcomed with warmth and one can feel at ease during the stay. Although I was familiar with Malawi and many other African countries, one still needs to find the local rhythm every time. But naturally that applies to any country and culture one is to visit. 
In low-income country the poverty is felt very directly and that is the part of the cultural encounters that is hard to deal with. But respectfulness is very much part of Malawian culture too, so encounters with people of all walks are always very straight-forward and polite.



Host university did not organise any social activities as such, but individual hosts took me around and invited me to lunches and few times to dinner. People get up early and go to sleep early, even in towns, so social life happens during daytime and early evening.

Lilongwe and Blantyre, the two major towns where the campuses are situated are fairly quiet towns. Security is better that in surrounding countries, but where there is poverty there are people who use opportunities if such arise. Thieving and pickpocketing are common, but violence less so, but one does not walk around alone after dark in urban areas nor in rural areas. 

Lake Malawi covers one third of the country and if possible, a visitor is encouraged to visit the lake-area. Nature-tours are organised too, although the wildlife is limited. Malawi is still trying to find its way in utilising its natural resources to attract tourists and as the infrastructure is very poor (roads) and rainy season harsh, it seems a long way to go. And naturally it affects the ways of organising health-care too.

As the transport can be challenging the community practises for midwifery, nursing and medical studies are usually done in sites not too far away from town. It seems to affect the way research sites are chosen too.    


My exchange-visit agenda

7.9.  Arrival to Lilongwe (flight Helsinki-Stockholm-Addis Abeba)
8.9. Lilongwe Campus of Kamuzu College of Nursing: Prof A Kazembe 
11.9 Blantyre Campus of KCN: Prof E Chirwa
12.9 Students Community projects
13.9 Central Hospital Maternity ward: newly graduated students
14.9 Community hospital session with student and student preceptor
15.9 Post graduate student research- sessions
18.9 Rural central hospital of Mangochi 
19.9 Rural Lungwena health centre and maternity waiting home and maternal and newborn research
20.9 Rural community maternity care- midwifery technicians
21.9 Blantyre Campus
22.9 Faculty seminar
26-29.9 Lilongwe Campus
Faculty Seminar, Maternity waiting home development, Birth centre project and entrepreneurship in midwifery studies
30.9 Departure from Lilongwe (Addis-Stockholm) and arrival to Helsinki on 1.10.17

Annan verksamhet

As I have been involved with the host country Malawi earlier in coordinating a sexual heath project there and also currently working on a research project in male involvement in family planning, my teacher exchange visit allowed me also to engage in dialogue on these themes with researchers and clinicians within College of Medicine and NGOs in Southern Malawi, in Mangochi. 

As I also have been working as an independent midwife in my natal Finland, the entrepreneur theme was found interesting by Malawian colleagues who were trying to find through possible private services ways to provide improved services. Kamuzu College of Nursing had initially made plans to start a small private birth centre next to the College that could serve as a site for optimal woman-centred care but that could also be a profit-making rather than only donor-driven. A building had already been erected and small number of midwives were working in it, but it was not yet running properly. Malawians counterparts were thus interested in getting assistance in private health service provision and birth centre- practise while also wanting to create a window or a show case rather to how good care look like and having students to have an opportunity to practise in it.

Kamuzu College of Nursing was particularly interested in improving its Masters and PhD-level education and showed enthusiasm in deepening the ties with KI in creating supervisor-collaboration and teacher-exchange in research projects.



Karolinska Institutet's Teachers Exchange Program / KI Lärarutbyte Program

As a midwife-researcher and clinician with several years of experience in coordinating a sexual and reproductive health project in Malawi, I was thrilled to be part of teachers' exchange program between KI's and Malawi's respective midwifery education programmes. Initially the planned exchange would contain three elements: teaching of Malawian midwifery students, participation in furthering new elements to Malawian midwifery education and incorporating student participation in action-based research by Malawian midwifery educators.

Prior to exchange visit several planning meetings were held with professor Helena Lindgren. Also during the exchange visit of two Malawian midwifery professors in Stockholm in May several meetings were held in planning my visit to Malawi. 

Pre-visit preparations focused on content as I already had pre-knowledge of the country and its culture. Visa was to be attained after landing (for visits less than three months), I had still valid compulsory vaccination of yellow fever and only malaria profylaxis prescription was needed.

Initial planning included one's visit to both Malawian campuses of midwifery in capitol Lilongwe and Blantyre as well as staying for a while in rural site of Mangochi. Tickets were booked for departure on 7th September and return on 30th September 2017         


Teacher-exchange is very important. 

Despite current technologies facilitating communication between individuals and institutions far apart, there is nothing quite the same as communicating live. And being together inhaling ways one's collaborators come from. That way the medical, midwifery and nursing students go through a 'learning by living' course in Malawi whereby they spend several weeks in rural areas to understand how different living can be within one's own country. So spending several weeks in a foreign country while having a powerful combining element, our joint profession, connecting you to new people, gives life to many new understandings.

I have no negative experiences, except that shortly before leaving Malawi I got high fever and was afraid of having contracted malaria, but a pile of positive ones. The eagerness all the midwifery colleagues, researchers and students alike engaged in topics I introduced, the willingness to educate the visitor and frankness in needing practical solutions, the kinds that are feasible in a poor country. 

In the weeks I spent in Malawi I got very involved with the staff of the college and can see very possible linkages between KI and KNC in developing Malawian midwifery research and post graduate studies but also having the Malawians to bring the understanding of global health and creating healthcare to masses with limited resources. Much learning to be done both ways.

Teachers' exchange works like a natural glue and I think it is very meaningful way to keep globality in midwifery education. I have talked about my Malawi-visit ever since I returned and I hope that some of the joint projects envisioned during my visit could see the daylight in not too far future. 


Malawian midwives are taught very good practical skills and midwifery values, but as it is often hard to practise the optimal midwifery care in Western settings. the reality in low-income countries like Malawi often means reacting to situations only when they get worse. Midwifery educators in Malawi are well aware of the limitations but at the same time I encountered eagerness in learning and adapting new ways when they are seen practical.

During my exchange-visit I was involved in various types midwifery educational activities. Kamuzu College of Nursing teaches midwives in undergraduate as well as at Masters and PhD levels. Also a new cadre of midwifery technicians has been included in recent years to respond to high need of trained midwives both in towns as well as in rural health centres. The number of student intake has also annually increased and new campuses have been built to cater for the increasing numbers, but with limited number of teachers, there are major hinders when teaching practical skills. That in turn reflects to practical study phases as the hospitals where students are doing their practicals are overcrowded by patients with small number of hospital staff to attend to patients, so students learn a lot through being innovative in situations that are not always learning situations with supervisor. 

I was involved with students in their community practicals. As Malawi has only few cities, the semi-urban and rural communities are in majority. As part of their studies, midwifery students do several practicals in the communities (antenatal checks, family planning and community health surveillance) to better understand the women and families they are to serve. Through interviewing and observation groups of students found needs and then planned ways to improve situations as was the case with the group pictured above who found out that in the community they were assigned to transferring of women in labour to maternity facility was a problem and they managed to arrange two bicycle ambulances to the community. Teacher and students then trained a group of community volunteers for their use and to understand the meaning of brisk transporting of labouring women with alarm signs. 

Although most student midwives are interested in facility-based midwifery, in a country with large rural and semi-urban population, a focus on community midwifery is important and the field practicals clearly opened many innovative ways to learn about the ways of their future patients and clients, even when working in facility. Learning of clinical skills in clinical labs of the college are very important but due to high number of students individual attention was not easy to arrange and lack of materials also made the task harder.    

Malawi's maternal and child mortality rates have decreased successfully but the growing population keep the hospitals crowded, Students trictly in supine position in bed) and with the results she gained, she moved on to bring alternatives to field with first training the co-educators who in turn will teach midwifery students and hospital midwives alike. As I am not part of Karolinska staff, I cannot directly compare with KI and Kamuzu College of Nursing, but the midwifery education and hospitals and health centres where students will be eventually working, are closely connected. But as stated earlier, limited resources create hinders to good teaching as well as to good midwifery care.

Malawian midwifery students (both undergraduate and post graduate Masters students) with whom I worked, showed great eagerness to move forward in educational and career paths. Interest in researching issues and themes midwives encountered in their care was high, but unfortunately very few had financial possibilities to go further as scholarships are hard to come by. In both Lilongwe and Blantyre maternities several midwives had observed less than optimal situations that needed correcting and went on to study alternatives that could be used to better the situations in newborn care, early breastfeeding and better positions for second stage of labour. Group discussions on these and many topics turned out fruitful also as part of my exchange teacher visit as different ways and views tend to get us to see things differently. 

My teacher exchange visit thus comprised of community midwifery group discussions in health centres, facility-based sessions with newly graduated, planning sessions with staff on the use of waiting homes for pregnant mothers, reviewing of plans for Master's studies with students who have work experience and several sessions with midwifery educators on clinical skills labs as well as on creating models of teaching that could involve both the KI students and local midwifery students into joint projects.





In three weeks I had 35 hours of teaching in various forms
Week one 18 hours
Week two 10 hours
Week three 7 hours

80% took place in group or individual settings, mostly on site or in community (semi-urban and rural).
20% involved interaction with midwifery educators and preceptors of midwifery students in facilties
I also visited four different waiting homes for pregnant mothers and collaborated in planning a study that would improve the use of them both clinically and in ways that involved midwifery students and their pre-natal practicals.